Practical Management of MS in the Primary Care Office Setting

Case Study 1

•Mr. P, a 33-year-old right-handed white man, developed numbness and tingling in his feet up to his mid-shins 4 days prior to presentation

•3 days ago, he noted sacral and anal numbness

•1-2 days ago, the numbness and tingling ascended to involve the left side of his abdomen and upper back

•He denies weakness, difficulty with walking, visual changes, vertigo, incoordination, bowel or bladder dysfunction

•He has paresthesias with neck flexion

Case 1: Clinically Isolated SyndromePresentation

• Personal history– Currently limited to 5 beers/week– Occasional marijuana use, no heroin or cocaine– Current medications: none

• Family history: No known history of neurologic illnesses

Case 1History

Case 1Examination

• General: normal• Neurologic

– Mental status: normal– Cranial nerves: normal– Motor: normal– Sensory:

• Decreased light touch and pinprick to T7 on the left and T12 on the right

• Lhermitte’s: positive

– Coordination: normal– Reflexes:

• 3+ left triceps and biceps• Otherwise 2+ throughout with downgoing toes

– Gait: normal

Case 1Brain MRI, Axial FLAIR

Case 1Brain MRI, T1 Hypointense Regions

Case 1Brain MRI, T1 Postcontrast

Case 1Cervical Spine MRI

Case 1Differential Diagnosis

Partial transverse myelitis• Lupus• Sarcoid• Multiple sclerosis• Other?

Case 1Hospital Course

• Patient admitted for further evaluation• Lyme, ANA, ENA, RPR, B12, HIV, ESR, and

CRP were unremarkable•CSF

–Protein, glucose, cell count and opening pressure were WNL

–9 oligoclonal bands in CSF that are not present in serum

Questions for Discussion

1. Does this patient meet diagnostic criteria for MS?– If not, what else is needed?

2. Should this patient be offered disease-modifying

MS therapy?